Medical Education

2y ago
319.86 KB
9 Pages
Last View : 17d ago
Last Download : 6m ago
Upload by : Randy Pettway

STANDARD POLICY and/or PROCEDUREMedical EducationTITLE: Corrective Action, Grievance and DueProcessColumbus, OhioISSUED: March, 2016NUMBERME-1000.047EFFECTIVE: April 15, 2016DISTRIBUTION:GMEC: Doctors, Dublin, Grant, O’Bleness, and RiversideMedical Education DepartmentsResidency and Fellowship Program DirectorsResident and Fellow PhysiciansOhioHealth Academic CouncilDEVELOPED BY: Medical Education & Office of the General CounselREVIEWED BY:Graduate Medical Education Committees:Doctors, Dublin, Grant, O’Bleness andRiversideOhioHealth Academic CouncilOffice of the General CounselDATE:Dublin GMEC 7/26/16APPROVED BY: Office of the General CounselGraduate Medical Education Committees: Doctors, Dublin, Grant, O’Bleness,and RiversideSCOPEThis Policy is in effect for Graduate Medical Education training programs at Doctors Hospital,Dublin Methodist Hospital, Grant Medical Center, O’Bleness Hospital, and Riverside MethodistHospital (each “Hospital” individually and “Hospitals” collectively). This Policy applies to allinterns, residents and fellows (“Resident/Fellow” individually and “Residents/Fellows”collectively) in the Hospitals’ training programs. Each training program is responsible fordetermining the academic standards required for satisfactory progress through each year of studyand the completion of the requirements. These standards must be approved by the GraduateMedical Education Committee (“GMEC”) of the Hospital.STATEMENT OF PURPOSEThe purpose of this Policy is to establish procedures for initiation of remediation and to provideguidance for the fair resolution of disputes regarding the Resident/Fellow's professionalperformance, conduct, and eligibility to continue in the Graduate Medical Education Program, or1Office of the General Counsel 148811v1

for the adjudication of Resident/Fellow's complaints and grievances regarding the workenvironment or to issues related to the program or faculty. This Policy expressly supersedes anyother appeals or grievance policies at the Hospital pertaining to Residents/Fellows. No otherpolicies or procedures available to medical staff members or employees of the Hospital apply toResidents/Fellows.POLICY STATEMENTRemediation is the process by which rule violations or deficiencies in performance aredocumented, called to the attention of the Resident/Fellow, and resolved. Remediation is intendedto be a learning opportunity, but in some cases the deficiency may warrant Corrective Action. ThisPolicy defines two types of Corrective Action: Non-Adverse Corrective Action and AdverseCorrective Action. When the proposed Corrective Action has an adverse impact on theResident/Fellow's participation in the training program it is Adverse Corrective Action and theResident/Fellow, in most instances, is entitled to appeal the recommendation before it goes intoeffect. This policy sets forth the process for appealing recommendations for Adverse CorrectiveActions.Any time written notice is required pursuant to this Policy the written notice shall be a hard copyand shall be personally delivered or sent by certified mail, return receipt requested, by regular U.S.Mail, and by e-mail with a return receipt requested.REMEDIATIONRemediation is used when rule violations or deficiencies in performance have been identified, andis intended to provide the Resident/Fellow with notice about areas that must improve or CorrectiveAction could result. The first goal of each training program when a Resident/Fellow demonstratesdeficiencies in performance should be, in most cases, to provide support to help theResident/Fellow improve. The Program Director shall review all reports alleging rule violationsor deficiencies in performance and shall meet promptly with the Resident/Fellow to discuss anyreports which the Program Director believes to have substance, and shall place a written accountof the meeting, including pertinent discussion, problems identified, and plans for remediation inthe Resident/Fellow’s file. This shall not require the Program Director to meet with theResident/Fellow after every negative performance evaluation, but the Program Director shall meetwith the Resident/Fellow upon indication that the negative performance evaluation(s) indicatedeficiencies in performance in need of remediation under this Policy.Remediation may consist of Non-Adverse Corrective Action or Adverse Corrective Action in anyof the ACGME, AOA, or CPME competency areas as appropriate. Corrective Action may be takenin the interest of improving the performance of a Resident/Fellow, in the interest of patient safety,or in the interest of the training program as a whole.Non-Adverse Corrective Action"Non-Adverse Corrective Action" means any action which is intended to call attention to andcorrect a deficit in the performance of a Resident/Fellow, whether in academic, professional,or behavioral areas, but which does not limit, restrict, or preclude the Resident/Fellow'scontinued participation in the training program. Non-Adverse Corrective Action includes2

negative performance evaluations, verbal counseling, written counseling, work improvementplans, and similar actions intended to improve performance. A Non-Adverse Corrective Actionwhich does not result in the desired improvement may become an Adverse Corrective Action.Adverse Corrective ActionAn "Adverse Corrective Action" has the potential to preclude the Resident/Fellow from actualparticipation in the residency/fellowship program, e.g., repeating one or more months of theprogram due to performance deficiencies, suspension or non-renewal or termination of theResident's contract. Only Adverse Correction Actions are subject to appeal or grievance.The following is a non-exhaustive list of Adverse Corrective Action:1. Repetition: Repetition is the decision to require a Resident/Fellow to repeat one or moremonths, up to a full year, of the training program due to performance deficiencies. (Adeferral due to leave of absence from the training program is not repetition.)2. Suspension: Suspension is the removal of the Resident/Fellow from training programactivities for a period of time, with the intention of returning to the training program. Theperiod of time may be defined in terms of days, weeks, or months, or it may be defined asthe time needed to fulfill certain stated conditions. A suspension may be without pay.3. Probation: Probation shall be used for Residents/Fellows who are in jeopardy of notsuccessfully completing the requirements of the training program or who are notperforming or behaving satisfactorily. Conditions of probation shall be communicated tothe Resident/Fellow in writing and should include: a description of the reasons for theprobation, an individualized remediation plan, and the expected time frame for the requiredremedial activity. Failure to correct the deficiency within the specified period of time maylead to an extension of the probationary period or other adverse corrective actions. Theprobationary period should not be less than 30 calendar days and its duration should beappropriate for issue(s) of concern.4. Involuntary Termination: "Termination" as used in this Policy refers to the decision toend a Resident/Fellow's contract prior to the normal expiration date, other than as part of amutually-agreed upon transfer to another program. The voluntary termination of theResident/Fellow’s contract by the Resident/Fellow or other voluntary departure from thetraining program is not a “Termination” under this Policy.5. Summary Suspension: Summary Suspension is a suspension that takes effect withoutprior notice and remains in effect during the appeal process, if any. Because of its disruptivenature, Summary Suspension may be imposed when the Resident/Fellow's activitiesjeopardize the safety of patients, peers, staff, or visitors, or could significantly disruptHospital operations or when substantial material questions arise related to but not limitedto (a) the Resident/Fellow’s failing to obtain or maintain required licensure, no longermeeting the qualifications for licensure, failing to obtain or maintain a degree or credentialnecessary to participate in the program or necessary to obtain or maintain licensure or3

certification, or failing to satisfy fundamental program or hospital requirements; (b) failingto comply with program or hospital training rules and regulations; or (c) committing afelony or other crime that could preclude the Resident/Fellow from practicing medicine orparticipating in the program. Summary Suspension may be recommended by the ProgramDirector and must be approved by the Director of Medical Education. SummarySuspension can be followed by recommended Corrective Action, reinstatement, ordismissal. Residents/Fellows placed on Summary Suspension will generally remain onpaid administrative leave during the appeal process (if an appeal is filed), although theprogram may, in its sole discretion, terminate paid administrative leave and place theResident/Fellow on unpaid leave beginning thirty (30) calendar days after the date ofsuspension.6. Summary Dismissal. When a Termination is recommended, in severe or egregiouscircumstances, a Summary Dismissal may be imposed. Severe or egregious circumstancesinclude but are not limited to: (a) the Resident/Fellow failing to obtain or maintain requiredlicensure or no longer meeting the qualifications for licensure, failing to obtain or maintaina degree or credential necessary to participate in the program or necessary to obtain ormaintain licensure or certification, or failing to satisfy fundamental program or hospitalrequirements; (b) willful, flagrant, or gross failure to comply with Hospital or trainingprogram rules and regulations, (c) the arrest of the Resident/Fellow on felony charges orother crimes that could preclude the Resident/Fellow from practicing medicine, or (d)actions that demonstrate a threat to the safety of patients, peers, staff, or visitors, or to theoperations of the Hospital.PROCESS FOR CORRECTIVE ACTIONNon-Adverse Corrective Action.Non-Adverse Corrective Action may be undertaken by the Program Director at the ProgramDirector's sole discretion. A written copy documenting the Non-Adverse Corrective Action shallbe placed in the Resident/Fellow's academic file. If the Non-Adverse Corrective Action includesa time period by which certain performance goals must be reached, the Program Director shalldocument in writing and place in the Resident/Fellow's academic file the Resident/Fellow's successor failure to achieve such goals.Adverse Corrective Action.The Program Director may recommend initiation of Adverse Corrective Action, including but notlimited to any of the types of Adverse Corrective Action listed above.While it is generally intended that the Resident/Fellow will be given the opportunity to improveand correct deficiencies and that remediation will be progressive, the Program Director is notrequired to use informal remediation or Non-Adverse Corrective Action prior to therecommendation of Adverse Corrective Action or to progress through types of Adverse CorrectiveAction in every circumstance. Depending on the facts and circumstances of each situation, the4

Program Director may recommend Adverse Corrective Action at any stage in the process ofremediation.Adverse Corrective Action shall be undertaken as follows: The Program Director shall assembleall documentation supporting the need for the Adverse Corrective Action, and then shall consultwith the Director of Medical Education (“DME”) and:1.The Program Director and DME shall consult with members of the ClinicalCompetency Committee, faculty, the GMEC, or other advisors deemed appropriate.2.The Program Director shall prepare a written notice to the Resident/Fellowsetting out the proposed Adverse Corrective Action, which shall include (a) thereasons for the action, with enough specificity for the Resident/Fellow tounderstand and respond; (b) the duration of the Adverse Corrective Action, ifany, and the conditions that must be fulfilled before the suspension is lifted, ifapplicable; (c) the ramifications of the Adverse Corrective Action upon theResident/Fellow's expected completion or graduation date; and (d) the processby which the Resident/Fellow may appeal the recommendation, with a copy ofthis Policy attached to the notice. This notice shall be presented to theResident/Fellow in a face-to-face meeting in which the Program Directorreviews the proposed Adverse Corrective Action and the reasons for it. If sucha meeting is not possible, then the written notice shall be sent to theResident/Fellow by both certified mail, return receipt requested, by regular U.S.Mail, and by e-mail with a return receipt requested.3.The Resident/Fellow shall have ten (10) business days (Monday throughFriday) from receipt of the written notice to initiate an appeal of the proposedAdverse Corrective Action. Such request must be in a written notice submittedto the DME and must be received within the ten (10) period.a.If the Resident/Fellow does not submit a timely request to initiate anappeal, the proposed Adverse Corrective Action shall then take effect.b.If the Resident/Fellow does submit a timely request to initiate an appeal,then the appeal shall proceed in accordance with the Appeal Procedureset forth below.Summary Suspension or Dismissal.If the proposed Adverse Corrective Action is a Summary Suspension or Summary Dismissal, allthe steps set forth above under Adverse Corrective Action shall apply, however, the SummarySuspension or Dismissal shall take effect immediately and shall remain in effect unless and untilthe decision is reversed or modified through the Appeal Procedure described below.APPEAL PROCEDURE AND DUE PROCESS5

The Department of Medical Education and the GMEC intend that Residents/Fellows be treated ina fair, reasonable and equitable manner. Toward that end, and consistent with ACGME and AOAInstitutional Requirements, the training program has established the following policies andprocedures for appeals and grievances.Adverse Corrective Action Appeal Procedure1.Request. If an appeal of Adverse Corrective Action recommendation is properlyrequested, as described in Section 3 of “Adverse Correction Active above,” or a grievanceis referred, as described in “Grievance Procedure” below, then this procedure shall beinitiated.2.Review Subcommittee.a.Appointment: Within a reasonable time following receipt of the written appeal orgrievance request, the DME shall send copies of the grievance/appeal to the involvedProgram Director and the Chair of the GMEC. The Chair of the GMEC shall name asubcommittee of the GMEC to hear the intended action. The subcommittee shallconsist of three (3) members who were not directly involved in the alleged offenses.The subcommittee will ideally be comprised of members of the GMEC who are indepartments other than the Resident’s/Fellow’s. The Chair of the GMEC may serveon the subcommittee unless he or she is also the DME. If necessary, members of thefaculty who are not a part of the GMEC can be appointed to the subcommittee. TheDME shall notify the Resident/Fellow of receipt of the appeal/grievance request andof the membership of the subcommittee.b.Record: In an appeal of recommended Adverse Corrective Action, the ProgramDirector shall submit all underlying materials regarding the recommended AdverseCorrective Action, including the written notice given the Resident/Fellow, to thesubcommittee upon appointment. In a grievance hearing, the Program Director shallsubmit all underlying materials regarding the grievance, including the writtencomplaint of the Resident/Fellow.c.Meeting: Within twenty (20) business days of its formation, the subcommittee shallmeet to hear the Resident/Fellow’s grievance or appeal from the recommendedaction. The hearing proceedings will be closed, except for as noted below.d.Purpose: The purpose of the review is to determine if there is sufficient evidence, inthe subcommittee’s opinion, to support the recommended Adverse CorrectiveAction or Resident/Fellow complaints and grievances related to the workenvironment or issues related to the program or faculty.e.Notice: The Resident/Fellow is entitled to at least five (5) business days’ notice ofthe date, time and place of the hearing. Notice shall either be by personal delivery orby both certified mail, return receipt requested, by regular U.S. mail, and by e-mailwith a return receipt requested.6

f.3.Advance Submission: At least three (3) business days in advance of the hearing, boththe Program Director and the Resident/Fellow may submit to the DME fordistribution to the subcommittee, with a copy to each other, any written statementsand/or documentation they wish the subcommittee to consider. Supportingdocumentation may not be introduced at the hearing unless included in this advancesubmission. The subcommittee may request additional information to be submittedas advance submission in at its discretion. If either side wishes to have witnesstestimony at the hearing, a request to allow such testimony, identifying the witnessand nature of testimony, shall be submitted to the subcommittee as an advancesubmission.The subcommittee shall notify the Program Director andResident/Fellow whether or not witness requests will be permitted at least one (1)business day prior to the hearing.Hearing.a.The subcommittee may, at its discretion, request the presence of an attorney for thesole purpose of advising the subcommittee on procedure and other legal issuesarising from the subcommittee's deliberations. Such attorney shall not act as anadvocate for either the Program Director or the Resident/Fellow and shall make nopresentations other than responses to questions from subcommittee members. TheDME (or Chief Academic Officer in the absence of the DME) shall attend thehearing as an observer but shall not be present during the subcommittee’sdeliberations.b.The Program Director (or designated faculty member in the absence of the ProgramDirector) shall present the proposed Adverse Corrective Action on behalf of theProgram, as well as the reasons for it. The Program Director may present anydocumentation in support of the proposal, provided that documentation has beenidentified and shared with the Resident/Fellow in advance. The Program Directormay not use an attorney to present the reasons for the recommendation. Thesubcommittee may ask any questions it has for the Program Director.d.The Resident/Fellow shall be invited to appear before the subcommittee and presenthis or her evidence to support the complaints or grievance or objections to theproposed Adverse Corrective Action. The Resident/Fellow may be accompanied bya physician advocate from the Medical Staff, but may not have an attorney present.This advocate may advise the Resident/Fellow and offer statements prepared on theResident/Fellow's behalf. The subcommittee may ask any questions it has for theResident/Fellow; questions directed to the Resident/Fellow must be answered by theResident/Fellow, not by the advocate.d.Order of Businessi.Call to Order and Introductiona. Members of the hearing subcommittee and counsel7 Resident/Fellow and physician advocate, if anyc. Program Director or designeeBrief review of proceduresPresentation of the proposed Adverse Corrective Action by the ProgramDirector, including the review of the written communication provided to theResident/Fellow and any supporting documentation. (exclusive of time forquestions asked by the subcommittee, this presentation shall not exceed 30minutes except with prior approval of the subcommittee).Presentation of the Resident/Fellow (exclusive of time for questions asked bythe subcommittee, not to exceed thirty (30) minutes except with prior approvalof the subcommittee).Rebuttal presentations and summary statements. The Program Director and theResident/Fellow may respond to each other's presentations, with the ProgramDirector going first. (Rebuttal shall not exceed ten (10) minutes per side exceptwith approval of the Subcommittee).Additional questions by the subcommittee to either party, if anyThe subcommittee may call a break or recess for deliberations at any time, butat the conclusion of the hearing the subcommittee shall adjourn to completedeliberations. The subcommittee may convene additional hearings in its solediscretion, and may limit the topics of such hearings if and as it deemsappropriate. If such additional hearings are called, the subcommittee shallprovide as much notice as possible to the Program Director and to theResident/Fellow. The subcommittee may call such additional hearings for thepurpose of interviewing witnesses called by the subcommittee. Additionalhearings shall be consistent with the provisions of this Section 3, except thatthe subcommittee may limit the statements, testimony, and questions to thosespecific issues to be resolved and to shorter times as deemed appropriate.Report and Recommendation. Upon completing its deliberations, the subcommitteeshall submit a written recommendation to GMEC. The subcommittee must reach theirdecision by a majority vote based upon the evidence presented. The recommendation canbe to:a.b.c.affirm the program's intended action, orrevise or modify the program's intended action, ornot affirm the program's intended action.A written copy of the subcommittee's recommendation will be given to theResident/Fellow.5.GMEC Action. The subcommittee's report and recommendation will be presented toGMEC at its next regular meeting. The report will be in writing and will give thesubcommittee’s recommendation and a brief description of the reasons for it. The GMECmay only accept or reject the subcommittee’s report and recommendation. The GMECwill vote on whether to accept or reject the report and recommendation.8

6.Final Decision. If the GMEC accepts the subcommittee’s report and recommendation, thereport and recommendation are the final decision. If the GMEC rejects the subcommittee’sreport and recommendation, the matter will be referred to the DME (or Chief AcademicOfficer in the absence of the DME) for final decision, and in that case, the decision of theDME (or Chief Academic Officer in the absence of the DME) shall be final and not subjectto further appeal or grievance.Grievance ProcedureWithin thirty (30) calendar days after an incident which forms the basis of a complaint or grievancerelating to the work environment or to issues related to the training program or faculty, to initiatethe Grievance Procedure the Resident/Fellow must submit a written statement to the DMEdescribing the grievance or complaint with enough specificity to allow the DME to understand thebasis of the grievance and respond to it. The written grievance or complaint must specify theviolation(s) alleged and the remedy sought. The Grievance Procedure will not be granted if theDME receives the request after the thirty (30) day period has expired. Failure to file within thirty(30) days forever bars the use of the Grievance Procedure by the Resident/Fellow. To the extentthat the DME determines the grievance has some validity, the DME may address the issue as heor she deems appropriate to resolve the grievance. To the extent that the DME determines that thegrievance has some validity and either (1) should be resolved with a hearing or (2) the DME haspreviously attempted to address the issue without a hearing and the Resident/Fellow believes thegrievance is not resolved, then the DME shall refer the grievance on for a hearing. The grievancehearing will follow the Adverse Corrective Action Appeal Procedure specified above.9

Riverside OhioHealth Academic Council . Riverside SCOPE This Policy is in effect for Graduate Medical Education training programs at Doctors Hospital, Dublin Methodist Hospital, Grant Medical Center, O’Bleness Hospital, and Riverside Methodist Hospital (each “Hospital” individually and “Hospitals” collectively). This Policy applies .

Related Documents:

What does the medical school of the future look like to you? Launched as an extension of the American Medical Association’s “Accelerating Change in Medical Education” initiative, our first-ever AMA Medical Education Innovation Challenge asked medical students and students of other health pro

That medical education was prostituted cannot be easily denied. Yet its beginnings, although short-sighted, were ambitious and hopeful. Nowhere in the world was eighteenth century medical practice or medical education based on pure science. Much of it was flagrant superstition. Even so, formal medical education in the United States began as a

ALABAMA BOARD OF MEDICAL EXAMINERS P.O. Box 946 / Montgomery, AL 36101-0946 / (334) 242-4116 MEDICAL SCHOOL & POST GRADUATE MEDICAL EDUCATION TRAINING Appendix A and B must be completed by all Medical Schools attended and all Post Graduate Medical Education Training Programs attended. You will note that the

The Complete Career and Technology Education System. 2 High-quality, industry-aligned Career and Technical Education exams at the course level, that help your students validate the . Clinical and Laboratory Procedures Medical Assistant - Medical Office Mgmt. Medical Assistant - Medical Terminology Medical Forensics

The Ohio State University Medical Center, Center for Continuing Medical Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. The Ohio State University Medical Center designates this educational activity for a maximum of 12.5 AMA PRA Category I .

Chelation therapy (Medical) For treatment of medical condition (lead poisoning) Chest rubs (Over the Counter: Meds & Drugs) (RX required after Jan. 1, 2011) Examples: Vicks Must be prescribed. Chiropractic care (Medical) Cholesterol tests (Medical) Christian Science practitioners (Medical) Circumcision (Medical) Co-pays (Medical)

Below is a map of the geographic coverage uai Molokai Oahu 1. Castle Medical Center 2. Kahuku Medical Center 3. Kaiser Permanente Medical Center 4. Kapiolani Medical Center for Women and Children 5. Kuakini Medical Center 6. Pali Marni Medical Center 7. The Queen's Medical Center Hawaii . · 8. Straub

Medical X-Ray Medical Imaging N/A N/A 5-100 Tc-99m Medical Imaging (SPECT) 6.02 hours J 140.5 Tl-201 Medical Imaging (SPECT) 73 hours H 135, 167 In-111 Medical Imaging (SPECT) 2.83 days H 171, 245 F-18 Medical Imaging (PET) 1.83 hours E 511 Ga-68 Medical Imaging (PET) 68 minutes E 511 Cs-137 Fission Product 30.17 years E- 662